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TRANSCRIPT
Guidance for Missouri School-Based Health Programs During the COVID-19 Pandemic
Updated on August 5, 2020
SHOW-ME SCHOOL-BASED HEALTH ALLIANCE OF MISSOURI 2
Table of Contents About this Resource ................................................................................................................................................ 3
About the Show-Me School-Based Health Alliance of Missouri ............................................................................. 4
Letter from the MOSBHA Executive Director ......................................................................................................... 5
Checklist of Considerations for Missouri School-Based Health Programs: Planning for the 2020-2021 School
Year ......................................................................................................................................................................... 6
Operations & Physical Space ...................................................................................................................... 6
Infection Control ......................................................................................................................................... 7
Addressing Student Needs .......................................................................................................................... 7
Support & Collaboration with School District Partners .............................................................................. 8
Community Partnerships ............................................................................................................................ 9
Summary Checklist of Considerations for MO School-Based Health Programs: Planning for the 2020-2021
School Year ............................................................................................................................................................ 10
Guidance for School Reopening ............................................................................................................................ 11
Resources .............................................................................................................................................................. 11
Additional Guidance for School Districts without an SBH Program ..................................................................... 11
Appendix A—FERPA COVID-19 CASE GUIDANCE: SCHOOL DISTRICT OFFICIALS .................................................. 12
Appendix B—HIPAA/FERPA COVID-19 CASE GUIDANCE: SCHOOL NURSES & SCHOOL-BASED HEALTH PROGRAM
STAFF ..................................................................................................................................................................... 18
Appendix C—COVID-19 PERSONAL PROTECTIVE EQUIPMENT BY RESPIRATORY PROTECTION TYPE ................. 23
Appendix D—RECOMMENDATIONS FOR THE CONSERVATION OF PPE DURING COVID-19 OUTBREAK FROM
ESSE HEALTH ......................................................................................................................................................... 25
Appendix E—MOSBHA CALLS FOR HEIGHTENED AWARENESS & PRIORITIZATION OF STUDENT MENTAL HEALTH
............................................................................................................................................................................... 28
SHOW-ME SCHOOL-BASED HEALTH ALLIANCE OF MISSOURI 3
About this Resource This resource was developed to support school-based health program (SBH) staff and their school district
partners in the reopening of services to students following school reopening during the COVID-19 pandemic.
The Alliance would like to thank the Membership Development and Education Committee of the Board of
Directors for their support in the development of this guidance. A special thanks also to the Missouri School
Board’s Association Center for Education Safety for the timely development of guidance on the reopening and
reopening of schools, which was the foundation for developing this guidance specifically for SBH programs.
This document will be updated periodically to remain timely. The guidance and considerations presented
herein are intended to be used as a template for guiding local discussions. Given variation in the impact of the
COVID-19 pandemic across Missouri as well as the unique local response, all decisions should be made in
close collaboration with local school districts and public health authorities.
For questions or suggestions for improvement, please contact the Alliance at [email protected] or
(800) 807-8494.
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About the Show-Me School-Based Health Alliance of Missouri The Show-Me School-Based Health Alliance (MOSBHA) is the Missouri state affiliate of the National School-
Based Health Alliance, established to improve the health of children and youth by advancing and advocating
for school-based health (SBH) programs. MOSBHA connects stakeholders from across the state to learn from
and inspire each other and to leverage resources and expertise to increase access to healthcare for children by
promoting the continued growth of SBH.
SBH programs are critical healthcare access points that provide comprehensive services—primary,
behavioral/mental, and oral health care as well as prevention and early intervention services—to children and
adolescents in their school, a location that is safe, convenient, and accessible. Some SBH programs in Missouri
also serve families, school staff, and the community. SBH programs provide care through partnerships
between school districts and SBH providers, which include federally qualified health centers, local health
departments, community health centers, hospitals, and other community institutions. Currently, 55
organizations sponsor 684 SBH programs in Missouri, serving over 520,428 students. They operate in rural,
urban, and suburban Missouri communities, serving primarily low-income and medically underserved children
and adolescents who may otherwise have untreated chronic health conditions.
Decades of research support the role of SBH programs in reducing health care costs and removing barriers to
health care as well as improving attendance and school connectedness. The Community Preventive Services
Task Force, an independent panel of public health and prevention experts, recommends school-based health
centers, one type of SBH program, as an “effective intervention for improving health equity and influencing
health and educational outcomes.” SBH programs have many benefits, including improved student health
outcomes, continuity of care, and access to health care. They also increase student attendance and graduation
rates and decrease dropout rates as well as faculty and staff sick days for those programs who serve them in
addition to students. Due to the positive impact of SBH programs, they result in cost savings for state
government and the healthcare and education systems.
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Letter from the MOSBHA Executive Director
To Missouri school districts & school-based health & mental health providers,
Due to COVID-19, Missouri children and adolescents will likely not be in school again before the start of the
2020/2021 school year. For many who rely on school-based health (SBH) programs, this will lead to months of
untreated chronic illness, missed preventive care visits and required vaccinations, and compounded unmet
mental health needs as access to these programs has been limited. Many students and staff will also return to
school with the added trauma of having lost loved ones and the stress of economic instability within their
families.
We also know that COVID-19 will continue to be a threat in many communities when school returns, and SBH
programs will have a critical role to play as frontline responders in schools to control further spread. When
schools reopen, SBH programs can also provide preventative and routine healthcare related to COVID-19, as
well as other key physical, oral, and mental healthcare services for Missouri’s most vulnerable youth.
Healthcare programs and schools/districts must develop and maintain a collaborative effort—now more than
ever—to address student and school community needs. This document was created to support and foster
additional collaboration between existing SBH programs and the school communities they serve as well as
encourage school districts and healthcare providers to consider partnerships to address student needs. Our
guidance was based on school reopening guidance provided in the Missouri School Boards’ Association’s
Pandemic Recovery Considerations, which we recommend as an additional resource for schools and their SBH
program partners.
In addition to planning for the safe reopening of students, we urge you to also prioritize the social/emotional
well-being of students through your SBH program efforts as well as support you provide to school district
partners. A heightened awareness of and attention to trauma and mental health will be critical as well as
diligence to measures to prevent discrimination and stigmatization surrounding COVID-19. Additional focus
should be given to crisis response and maintaining fair discipline practices, as students will return to school
after several months of disruption in their daily routines.
Please do hesitate to reach out to us as you collaborate to plan for reopening your SBH programs and schools
amidst the COVID-19 pandemic.
Molly Ticknor
MOSBHA Executive Director
[p] (800) 807-8494 ext. 700
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Checklist of Considerations for Missouri School-Based Health Programs: Planning for the
2020-2021 School Year
Operations & Physical Space Create and/or adapt protocols for screening for the Coronavirus.
• Develop and implement screening questions and temperature check protocols for before
students/patients enter the SBH program space.
• Consider separating sick and well visits to prevent potential spread while still providing
preventative and routine care. Solutions may include scheduling sick vs. well appointments for
different times of the day or separating sick and well within the clinic space if possible.
• Create plans for isolation of suspected/symptomatic students. SBH programs with permanent
physical space within the school building may also be able to support the school by providing
additional space to support isolation measures.
• Consider who will have access to the center, including parents if accessing to attend an
appointment with their child or to take them home.
Develop plan for social distancing of students and staff.
• Current guidance from the Centers for Disease Control and Prevention recommends
maintaining 6 feet of distance between people. Following this guidance, determine flow of
traffic through the center.
• Consider using tape, signs, or other markers to alert students and visitors of where to stand.
• Consider current staffing within the SBH program space and whether altering schedules or
implementing a work-from-home policy for some SBH program staff would help to maintain
social distancing.
Determine if program will be testing for Coronavirus or referring to testing site.
• If referring to testing sites, know when testing sites near your center are open and their testing
criteria. Access a list of Missouri testing sites here.
• If testing within the SBH program, create the appropriate protocols, working closely with your
sponsoring agency and school leadership.
Evaluate the role of telemedicine in your program.
• Consider if your program will provide telemedicine visits if the school district resorts to e-
learning again.
• Consider consent processes for telemedicine visits—confirm you with organization’s legal
department what adaptations need to be made to existing consent.
• For programs who offer telemedicine exclusively, consider infection control/PPE measures for
the operator.
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Understand HIPAA/FERPA and privacy/confidentiality related to COVID-19 reporting, tracking,
isolation, risk reduction, etc. etc.
• See Appendix A for additional for school district officials as well as Appendix B for additional
guidance on HIPAA/FERPA for school nurses and SBH providers during COVID-19.
Infection Control Develop or adapt written protocol for disinfecting the SBH program space using EPA-approved
cleaning products.
• Follow guidance from the CDC on cleaning and disinfecting in their Cleaning and Disinfecting
Guide.
• A list of EPA approved products is available here.
• An alternative cleaning solution is bleach solution. Combine 1/3rd cup bleach per gallon of
water.
Procure adequate PPEs, including masks for staff and students, gloves, and gowns.
• Educate staff about use of PPE. Post instructions or infographics as reminders. See Appendix A
for detailed recommendations on PPEs.
• Consider protocols for the conservation of PPEs—see Appendix B for additional guidance on
conserving PPEs during COVID-19.
Consider updating protocols to address asthma exacerbation without the use of a nebulizer.
• Consider the use of MDIs (metered dose inhalers) in place of the use of a nebulizer.
Promote prevention of infection including handwashing in the clinic and encourage it throughout the
school day.
• Several posters/resources for educating about handwashing include the Stop the Spread Poster,
CDC Handwashing Resources, and MODHSS Cover Your Cough and Handwashing Posters
Addressing Student Needs If you do not already screen for these, consider implementing systemic screening for food insecurity
and depression.
• Prepare resource handouts or work with a community partner to prepare resource guides to
assist families in enrolling in Medicaid and SNAP benefits.
• Determine clinic protocol for screening, scoring, and connecting to resources during patient
visits. Screening tools to consider, based on population, include PREPARE, Arizona Self
Sufficiency Matrix, and the Healthy Kids Social Service Assessment.
Heighten efforts to collect signed parent/guardian consent forms.
• Considering that students may need to be seen quickly, consider changes to the process if
student w/o consent presents w/ symptoms.
SHOW-ME SCHOOL-BASED HEALTH ALLIANCE OF MISSOURI 8
Communicate, in partnership with school district partners, the services offered at the school-based
site and reiterate enhanced infection control measures to help assure parents/guardians it is safe for
students to be seen by the SBH program.
• Develop combined communication plan with school leadership. Determine who communicates
what and through which communication channels.
• Consider posting SBH information and updates on district website or social media platforms as
appropriate.
Support & Collaboration with School District Partners Collaborate early and often with school administrators and school nurses.
o Schedule periodic meetings throughout the summer.
o Support school district in making decisions related to the school reopening process. It is
essential to include all community stakeholders as school and SBH reopening plans are
developed to ensure that each organization is following current policies and procedures.
o Help to establish protocols related to screening and assessing symptoms and the establishment
of school cleaning and sanitizing procedures.
o Review and update the plan on a regular basis to ensure the highest level of success in
responding to and meeting the healthcare needs of the students.
o If possible, support school staff and school nurses with medical supplies such as PPEs and
thermometers.
Determine health priorities to address student needs.
o Given the lapse in care many students will have experienced throughout school closures and
COVID-19, discuss with school partners what the school-based health program should prioritize.
Immunizations? Mental health? Reproductive health?
Review plans for addressing suspected COVID-19 cases of students or staff.
o Determine if the SBH program will assist in the determination of suspected cases of COVID-19
or provide a space for student isolation.
o Discuss who can receive your school-based health services and if it changes given COVID-19–
students only, students and staff, community members, etc.?
Partner to provide education for school staff on the symptoms of COVID-19.
o Help to provide education on the signs and symptoms of COVID-19, when students should be
sent to the nurse’s office and/or the SBH program, and precautions to take.
Review plans for students in crisis or who are suicidal.
o Determine how the SBH program will play a role to support crises.
Partner to prepare trainings on trauma-informed practices and resiliency for teachers and SBH
program staff.
SHOW-ME SCHOOL-BASED HEALTH ALLIANCE OF MISSOURI 9
o Leverage local trauma-informed practice trainings and resources to prioritize resiliency in
responding to student needs.
Community Partnerships Reach out to your local health department as early as possible and determine their role and
expectations.
• Some local health departments have received additional funding to provide PPEs for local
entities such as schools and they will be key partners if they are contact tracing.
Consider developing a community-based task force to address student needs and determine what
stakeholders should be present.
• Key partners to engage may include school leadership, your local health department,
parent/teacher organization, or hospital/health system.
Collaborate with school social workers and community partners to create resource referral lists (or
on-site services) for students and families.
• Clearly define roles and responsibilities of SBH staff and school support staff as they relate to
addressing student needs.
• Critical referrals to have ready include mental health resources, food, housing, utility
assistance, and employment support/workforce development.
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Summary Checklist of Considerations for MO School-
Based Health Programs: Planning for the 2020-2021
School Year
✓ d Responsible Task
Operations & Physical Space
Create and/or adapt protocols for screening for the Coronavirus.
Develop a plan for social distancing students and staff.
Determine if program will be testing for Coronavirus or referring to a testing site.
Evaluate the role of telemedicine in your program.
Understand HIPAA/FERPA and privacy/confidentiality related to COVID-19 reporting, tracking, isolation, risk reduction, etc. etc.
Infection Control
Develop or adapt written protocol for disinfecting the SBH program space using EPA-approved cleaning products.
Procure adequate PPEs, including masks for staff and students, gloves, and gowns.
Consider updating protocols to address asthma exacerbation without the use of a nebulizer.
Promote prevention of infection including handwashing in the clinic and encourage it throughout the school day.
Address Student Needs
If you do not already screen for these, consider implementing systemic screening for food insecurity and depression.
Heighten efforts to collect signed parent/guardian consent forms.
Communicate, in partnership with school district partners, the services offered at the school-based site and reiterate enhanced infection control measures to help assure parents/guardians it is safe for students to be seen by the SBH program.
Support & Collaborate with School District Partners
Collaborate early and often with school administrators and school nurses.
Determine health priorities to address student needs.
Review plans for addressing suspected COVID-19 cases of students or staff.
Partner to provide education for school staff on the symptoms of COVID-19.
Review plans for students in crisis or who are suicidal.
Partner to prepare trainings on trauma-informed practices and resiliency for teachers and SBH program staff.
Leverage Community Partnerships
Reach out to your local health department as early as possible and determine their role and expectations.
Consider developing a community-based task force to address student needs and determine what stakeholders should be present.
Collaborate with school social workers and community partners to create resource referral lists (or on-site services) for students and families.
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Guidance for School Reopening
Resources • Pandemic Recovery Considerations: Re-Entry and Reopening of Schools from the Missouri School
Board Association’s Center for Education Safety includes Missouri-specific considerations for school
reopening and is a critical resource for planning.
• The Missouri Department of Health and Senior Services (DHSS) and the Department of Elementary and
Secondary Education (DESE) released a document that answers frequently asked questions (FAQs)
about K-12 school reopening health-related guidance that is accessible here.
• Guidance for Preparing a Safe Return to School in Fall 2020 from the Centers for Disease Control and
Prevention will continuously be updated with national guidance on school reopening.
• The Return to School Roadmap is informed by best practices in public health and education emergency
operations. This interactive guide from The Opportunity Labs provides information on both the school
district and individual school levels.
• The National Association of School Nurses has released several resources providing guidance for school
nurses through planning for and returning to school, including Guidance for Healthcare Personnel on
the Use of Personal Protective Equipment (PPE) in Schools During COVID-19.
• The Washington University Pediatric and Adolescent Ambulatory Research Consortium and Children’s
Mercy Kansas City have both provided resources on reopening schools, including algorithms for
decision-making on screening and assessing COVID-19 in children and considerations for testing and
managing COVID-19 in children.
Additional Guidance for School Districts without an SBH Program • Proactively reach out to local health department to understand how they may be able to help support,
including potentially providing PPEs and other supplies.
• Reach out to federally qualified health centers (FQHCs) in your area for potential support. Visit the
Missouri Primary Care Association for a map of FQHCs in Missouri
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Appendix A—FERPA COVID-19 CASE GUIDANCE: SCHOOL DISTRICT OFFICIALS
SHOW-ME SCHOOL-BASED HEALTH ALLIANCE OF MISSOURI 13
FERPA COVID-19 Case Guidance:
School District Officials
FERPA Basics The Family Educational Rights and Privacy Act (FERPA) are federal laws that protect the confidentiality of
records maintained by public schools, including health records. This guidance was created to support school
district officials in understanding the application of FERPA related to the sharing of information on suspected
or confirmed COVID-19 cases. The purpose of this document is to assist school officials in protecting student
privacy in the context of COVID-19 as they consider the disclosure of personally identifiable information (PII)
from student education records to individuals and entities who may not already have access to that
information. School officials should work with their state and local public health officials to determine the
information needed to address this public health concern. Understanding how, what, and when information
can be shared is a critical part of preparedness. A sister resource with information on HIPAA & FERPA
pertinent to school nurses and school-based health program staff is also available.
Guidance for the Sharing of Records that Fall Under FERPA When a school district encounters a student with a confirmed or suspected case of COVID-19, there are
several audiences with whom the district will want to disclose information related to the sick student.
• Information about the student’s condition may need to be shared with the local health department
(LHD) for the purpose of complying with reporting laws. The Missouri Department of Health and Senior
Services has added COVID-19 to the list of conditions both schools and health care providers must
report under state regulation. 19 CSR 20-20.020.1 LHDs may also contact a school district for
information about a student in order to trace contacts related to suspected or confirmed cases of
COVID-19. For example, they could request information such as attendance records, parent/student
names, and contact information.
• School districts may feel the need to share information with parents/guardians of other students so
that they may be aware and take necessary additional precautions to protect their student(s) as well as
to prevent inaccurate rumors from spreading.
• Faculty and school staff will need to receive information about confirmed or suspected cases to take
necessary additional precautions to protect students. Information should only be shared with faculty
and school staff on a need to know basis.
• School-based health program staff may also need to be made aware of positive or suspected cases,
either if students are referred to them with symptoms or to also take necessary additional precautions
to protect students and other patients.
Before school districts share personally identifiable information
about a student, which is contained in a student record maintained by the district,
the district must make sure that it can legally disclose the information.
NOTE: This guidance should be used to support local decision-making and the development or updating of
local policies. It is not intended as legal advice.
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Applicable Exceptions—Guidance for Sharing Records that Fall Under FERPA
Depending on the circumstances, information may be disclosed in the following circumstances:
Information is not personally identifiable.
Information may always be shared as long as a student is not directly or indirectly identified. For example, stating that there has been an elementary student that has tested positive in a large district is typically not a problem because it is difficult to determine which student of many was the one. However, in a smaller district such a statement may not be appropriate in situations where very few students have been absent due to illness. When sharing information about a positive case, disclose the minimum amount of information required by each audience to take the necessary steps to protect themselves. It is often sufficient to release there was a positive case without sharing the student’s name or even classroom.
Parent/guardian (or sometimes student) consent.
If the district obtains written permission from the parent/guardian or eligible student, personally identifiable information about the student may be legally shared under FERPA. A student is “eligible” to consent if the student is 18 or is enrolled in postsecondary education.
A health and safety emergency.
FERPA’s health or safety emergency exception allows for the release of information without signed consent if:
o There is an “articulable and significant threat” to the health or safety of others AND
o It is necessary to protect the health or safety of the student or other individuals.
Thus, if a student tests positive for COVID-19 and the health department needs to contact all of the parents of the students in the same classroom, the school district can share with the health department contact information for those families if there is a current threat to the safety of those students. Although educational agencies and institutions can often address threats to the health or safety of students or other individuals in a manner that does not identify a particular student, FERPA permits educational agencies and institutions to disclose, without prior written consent, PII from student education records to appropriate parties in connection with an emergency, if knowledge of that information is necessary to protect the health or safety of a student or other individuals. Note: If the district uses this exception the information may only be shared with persons who need to know the information to address the threat (i.e., public health officials, trained medical personnel, and parents, including parents of an eligible student) are the types of appropriate parties to whom PII from education records may be disclosed under this FERPA exception. Within a reasonable period of time after a disclosure is made under this exception, an educational agency or institution must record in the student’s education records the articulable and significant threat that formed the basis for the disclosure and the parties to whom information was disclosed. 34 C.F.R. § 99.32(a)2
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Directory Information and Limited Directory Information
The district can designate some information contained in student records as not harmful or an invasion of privacy if released without signed consent. This is commonly referred to as “Directory Information.” If parents and student are notified of the definition of Directory Information and are given an opportunity to opt out and they do not opt out, then the school can disclose the information to any person without written consent. Directory Information can include some or all of the following information about a student:
Name, address, phone number, e-mail address, photograph, birthdate, grade level, enrollment status, dates of attendance, participation in activities and sports.
If a parent or student has not notified the district that they do not want this information released, the district may legally release this information under FERPA to the health department without parent consent. For example, if the health department notifies the school district that a specific student tested positive for COVID-19 and asked if that person was a student in the school, which grade the student was in, how long the student attended and if the student participates in activities and sports, the district could share that information without first obtaining written parent consent. Be careful! Just because a student’s name is listed in Directory Information does not mean that the school can announce to anyone the name of the student that tested positive for COVID-19. In the above circumstance, the school is not just releasing a name—it is releasing medical information about the student. Medical information cannot be Directory Information under FERPA because many feel it is an invasion of privacy to release it. Some districts have “Limited Directory Information,” which means that some information can only be released to identified persons or entities – not anyone in the community. For example, many districts only provide the address and phone number of students to governmental entities, not the general public. Before releasing information under the Directory Information exception, read the notice provided to the parents and student very closely to make sure that the district is only releasing information it said it would release.
Employee (or Contractor or Consultant) with a Legitimate Educational Interest
Employees with a legitimate educational interest may access student records even without signed consent. The definition of an “employee” is defined broadly to include contractors, consultants, volunteers, or others that 1) perform a service for which the school would otherwise use an employee, 2) is under the direct control of the school, and 3) that agrees not to redisclose the information unless allowed by law. Note: This includes school-based health (SBH) providers who are providing services within the school. If a school contracted with a health care provider to provide school nursing services, health information contained in a student’s records could be shared with the contracted nurse as long as there was a legitimate educational reason for sharing the information.
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Other Recommendations for FERPA & COVID-19 Cases
• Make all disclosures of information on a case-by-case basis based on the current situation.
• School districts, in planning for school reopening, may consider developing and collecting signed
consent forms delineating when, what, and to whom student information will be shared related to
COVID-19.
• When sharing information about a positive case, disclose the minimum amount of information
required by each audience to take the necessary steps to protect themselves. It is often sufficient to
release there was a positive case without sharing the student’s grade, classroom, or building.
• Document, in the student record, when information is released, to whom, and for what purpose.2
• Even when it is legal to disclose information in a student record, the district must be careful to only do
so when necessary and to protect students against discrimination or bullying that may result from the
disclosure.
Schools w/ School-Based Health Program Partners
If the school or district in partnership with a school-based health (SBH) program, whose records typically
adhere to the Health Insurance Portability and Accountability Act (HIPAA), becomes aware of a student with a
confirmed or suspected case of COVID-19, information about this student may need to be shared with the
school community.
Generally, information stored in the student’s educational record must be protected in accordance with
FERPA, whereas HIPAA protects the privacy of patient health information held by healthcare providers. The
two laws cannot apply to the same record at the same time. To determine whether records in a school
environment are subject to FERA or HIPAA, consider the source of the information.
• FERPA applies to personally identifiable student records maintained by schools or education institution
that receive federal funding, such as those records maintained by a school nurse.
• HIPAA applies to records of SBH programs that are funded, administered, and operated by or on behalf
of a public or private health or social services agency, such as a federally qualified health center,
hospital/health system, or local health department.
Both HIPAA and FERPA allow for the disclosure of records, or information contained in those records, to a
third party in a variety of circumstances. However, the easiest and best method under both HIPAA and FERPA
is to obtain written consent from a parent or guardian of a student. In some circumstances the student
themselves can consent to releasing the records. Under FERPA the student must be 18 or enrolled in a post-
secondary institution. Under HIPAA the student must be 18 or otherwise eligible to consent under state law.
Many school districts and healthcare providers co-develop a HIPAA/FERPA compliant consent form. The
form stipulates what information will be shared with whom and is required to be signed, along with a consent
to treat, before a student is eligible to receive SBH services. 3
Key Considerations for Navigating HIPAA/FERPA with COVID-19 Cases
• School districts should work in collaboration with their SBH providers for any communication to
students, parents, teachers, and the community to assure streamlined, joint messaging. SBH providers
SHOW-ME SCHOOL-BASED HEALTH ALLIANCE OF MISSOURI 17
and their school districts may also have agreements related to communication in their memorandum
of understanding (MOU), which should always be followed.
• Like FERPA, HIPAA allows for the release of information without signed consent for the purpose of
public health, including to public health authorities and to persons at risk of contracting or spreading
disease.
• Information should only be disclosed as necessary to prevent or control the spread of the disease and
only the minimum necessary information should be shared.
References
1. Missouri Register (2020). COVID-19 Emergency Amendment and Waivers of Administrative Rules. Retrieved
from https://www.sos.mo.gov/CMSImages/AdRules/moreg/2020/v45n5Mar2/v45n5a.pdf
2. U.S. Department of Education (2018). Family Educational Rights and Privacy Act (FERPA). Retrieved from
https://www2.ed.gov/policy/gen/guid/fpco/ferpa/index.html 3. Gudeman, R. (2018). HIPAA or FERPA? A Primer on Sharing School Health Information in California, 2nd Edition -
National Center for Youth Law. Retrieved from https://youthlaw.org/publication/hipaa-or-ferpa-a-primer-on-
sharing-school-health-information-in-california-2nd-edition/
Additional Resources
• Student Privacy During the COVID-19 Pandemic from the School Superintendents Association and Future of
Privacy Forum
• FERPA & Coronavirus Disease 2019 (COVID-19) Frequently Asked Questions from the U.S. Department of
Education
• FERPA and COVID-19 Virus DOE Guidelines from the National Law Review
__________________________________________________________________________________________
This resource was developed by the Show-Me School-Based Health Alliance’s HIPAA/FERPA Workgroup.
The Show-Me School-Based Health Alliance of Missouri is the statewide affiliate of the National School-Based
Health Alliance. We support communities in building and sustaining quality school-based health programs.
Our vision is that every child and youth in Missouri has an equal opportunity to success by assuring access to
high-quality health care.
[p] 800-807-8494 | [w] moschoolhealth.org | [e] [email protected]
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Appendix B—HIPAA/FERPA COVID-19 CASE GUIDANCE: SCHOOL NURSES & SCHOOL-BASED
HEALTH PROGRAM STAFF
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dHIPAA/FERPA COVID-19
Case Guidance:
School Nurses & School-Based
Health Program Staff About This Guidance The Health Insurance Portability and Accountability Act (HIPAA) and the Family Educational Rights and
Privacy Act (FERPA) are federal laws that protect privacy and confidentiality that apply in school-based health
(SBH) settings. This guidance was created to support school nurses and school-based health program
providers in understanding the application of these policies related to the sharing of information on suspected
or confirmed COVID-19 cases.
HIPAA vs. FERPA: The Basics Generally, information stored in the student’s educational record must be protected in accordance with
FERPA, whereas HIPAA protects the privacy of patient health information held by healthcare providers. The
two laws cannot apply to the same record at the same time. To determine whether records in a school
environment are subject to FERA or HIPAA, consider the source of the information.
• FERPA applies to personally identifiable student records maintained by schools or education institution
that receive federal funding, such as those records maintained by a school nurse.
• HIPAA applies to records of SBH programs that are funded, administered, and operated by or on behalf
of a public or private health or social services agency, such as a federally qualified health center,
hospital/health system, or local health department.
Both HIPAA and FERPA allow for the disclosure of records, or information contained in those records, to a
third party in a variety of circumstances. However, the easiest and best method under both HIPAA and FERPA
is to obtain written consent from a parent or guardian of a student. In some circumstances the student
themselves can consent to releasing the records. Under FERPA the student must be 18 or enrolled in a post-
secondary institution. Under HIPAA the student must be 18 or otherwise eligible to consent under state law.
Many school districts and healthcare providers co-develop a HIPAA/FERPA compliant consent form. The
form stipulates what information will be shared with whom and is required to be signed, along with a consent
to treat, before a student is eligible to receive SBH services. 1
Given the unique circumstance of COVID-19, school nurses and school-based health program providers should
include discussions around HIPAA/FERPA and the sharing of information related to COVID-19 cases as part of
their planning for the 2020/2021 school year. Understanding how, what, and when information can be shared
is a critical part of preparedness.
NOTE: This guidance should be used to support local decision-making and the development or updating of
local policies. It is not intended as legal advice.
SHOW-ME SCHOOL-BASED HEALTH ALLIANCE OF MISSOURI 20
Guidance for Records that Fall Under FERPA As the school nurse, if you encounter a student with a confirmed or suspected case of COVID-19, there are
several audiences who may need to know information about the sick student or who may ask questions if they
hear of the case. Work with your school and district leadership to establish policies related to each group,
including the following:
Local Health Departments
Information about the student’s condition may need to be shared with the local health department (LHD) for the purpose of complying with reporting laws. The Missouri Department of Health and Senior Services has added COVID-19 to the list of conditions both schools and health care providers must report under state regulation. 19 CSR 20-20.020.2 LHDs may also contact a school district for information about a student in order to trace contacts related to suspected or confirmed cases of COVID-19. For example, they could request information such as attendance records, parent/student names, and contact information. Establish a protocol for responding to LHD inquiries to your school, working closely with school leadership and your community’s LHD.
Parents/Guardians School districts may feel the need to share information with parents/guardians so that they may be aware and take necessary additional precautions to protect their student(s) and to prevent inaccurate rumors from spreading. All instances of sharing information with parents/guardians should be made in close partnership with school leadership.
School-Based Health Program Staff
School-based health program staff may also need to be made aware of positive or suspected cases, either if students are referred to them with symptoms or to also take necessary additional precautions to protect students and other patients. Existing MOUs between SBH programs and your school district may already delineate how health information is shared between partners. Information should only be shared with SBH program staff on a need to know basis and should always follow the stipulations of the MOU. In preparation for the 2020/2021 school year, include discussions about sharing information related to confirmed or suspected case of COVID-19 with your SBH program partners.
Faculty and School Staff
Faculty and school staff will need to receive information about confirmed or suspected cases to take necessary additional precautions to protect students. School administration can also expect staff to raise questions to each other. Information should only be shared with faculty and school staff on a need to know basis. Plan with school leadership how you will communicate information to confirmed or suspected cases and how you will respond to questions to ensure student confidentiality is protected.
Before the district shares information about a personally identifiable student that is contained in a student
record maintained by the district, the district must make sure that it can legally disclose the information.
Reference FERPA COVID-19 Case Guidance for School District Officials here to understand applicable FERPA
exceptions for legally disclosing COVID-19 cases.
SHOW-ME SCHOOL-BASED HEALTH ALLIANCE OF MISSOURI 21
Key Recommendations
• Make all disclosures of information on a case-by-case basis based on the current situation.
• Information may always be shared as long as a student is not directly or indirectly identified. When
sharing information about a positive case, disclose the minimum amount of information required by
each audience to take the necessary steps to protect themselves. It is often sufficient to release there
was a positive case without sharing the student’s name or even classroom, always considering the
release of information on a case-by-case basis to consider to whom information is being shared and for
what purpose.
• School districts, in planning for school reopening, may consider developing and collecting signed
consent forms delineating when, what, and to whom student information will be shared related to
COVID-19. Discuss this option with school leadership
• When sharing information about a positive case, disclose the minimum amount of information
required by each audience to take the necessary steps to protect themselves. It is often sufficient to
release there was a positive case without sharing the student’s grade, classroom, or building.
• Document, in the student record, when information is released, to whom, and for what purpose.3
• Even when it is legal to disclose information in a student record, the district must be careful to only do
so when necessary and to protect students against discrimination or bullying that may result from the
disclosure.
Records that Fall Under HIPAA If the SBH program, whose records typically must adhere to HIPAA, becomes aware of a student with a
confirmed or suspected case of COVID-19, information about this student may need to be shared with the
school community.
Sharing Information with School Districts
The primary audience for SBH programs to share information related to confirmed or suspected cases of
COVID-19 is the school district, including school nurses, district leadership, and staff/teachers. Under HIPAA, it
is generally easier to share student-related health information with the school district than the other way
around—entities covered under HIPAA may disclose information as necessary to treat the patient and in order
to prevent or control the spread of disease.4 SBH program providers should adhere to existing agreements
with their district partner in terms of information they may share with their school district partners.
Key Recommendations
• For SBH providers, all communication to students, parents, and teachers should be approved by their
school district partners before disseminating. This will assure streamlined, joint messaging. SBH
providers and their school districts may also have agreements related to communication in their
memorandum of understanding (MOU), which should always be followed.
• Like FERPA, HIPAA allows for the release of information without signed consent for the purpose of
public health, including to public health authorities and to persons at risk of contracting or spreading
disease.
• Information should only be disclosed as necessary to prevent or control the spread of the disease and
only the minimum necessary information should be shared.
SHOW-ME SCHOOL-BASED HEALTH ALLIANCE OF MISSOURI 22
References
1. Gudeman, R. (2018). HIPAA or FERPA? A Primer on Sharing School Health Information in California, 2nd
Edition - National Center for Youth Law. Retrieved from https://youthlaw.org/publication/hipaa-or-
ferpa-a-primer-on-sharing-school-health-information-in-california-2nd-edition/
2. Missouri Register (2020). COVID-19 Emergency Amendment and Waivers of Administrative Rules.
Retrieved from https://www.sos.mo.gov/CMSImages/AdRules/moreg/2020/v45n5Mar2/v45n5a.pdf
3. Reddy, A., & Vance, A. (2020). Student Privacy During the COVID-19 Pandemic. Retrieved from
https://aasa.org/uploadedFiles/AASA_Blog(1)/COVID-19%20Student%20Privacy%20FAQs%2003-20-
2020.pdf
4. Services, U. S. D. o. H. a. H. (2020). COVID-19 & HIPAA Bulletin Limited Waiver of HIPAA Sanctions and
Penalties During a Nationwide Public Health Emergency. Retrieved from
https://www.hhs.gov/hipaa/for-professionals/special-topics/hipaa-covid19/index.html
5. Missouri Register, (2020). COVID-19 Emergency Amendment and Waivers of Administrative Rules.
Retrieved from https://www.sos.mo.gov/CMSImages/AdRules/moreg/2020/v45n5Mar2/v45n5a.pdf
Additional Resources
• Student Privacy During the COVID-19 Pandemic from the School Superintendents Association and Future of
Privacy Forum
• FERPA & Coronavirus Disease 2019 (COVID-19) Frequently Asked Questions from the U.S. Department of
Education
• FERPA and COVID-19 Virus DOE Guidelines from the National Law Review
__________________________________________________________________________________________
This resource was developed by the Show-Me School-Based Health Alliance’s HIPAA/FERPA Workgroup.
The Show-Me School-Based Health Alliance of Missouri is the statewide affiliate of the National School-Based
Health Alliance. We support communities in building and sustaining quality school-based health programs.
Our vision is that every child and youth in Missouri has an equal opportunity to success by assuring access to
high-quality health care.
[p] 800-807-8494 | [w] moschoolhealth.org | [e] [email protected]
SHOW-ME SCHOOL-BASED HEALTH ALLIANCE OF MISSOURI 23
Appendix C—COVID-19 PERSONAL PROTECTIVE EQUIPMENT BY RESPIRATORY PROTECTION
TYPE
SHOW-ME SCHOOL-BASED HEALTH ALLIANCE OF MISSOURI 24
COVID-19 Personal Protective Equipment by Respiratory Protection Type*
Facemask or Cloth Face Covering Recommended
Any team member not interacting with patients or with limited public interactions
should wear masks or cloth face coverings if six feet of social distance cannot be
maintained. Wear gloves only if there’s possible exposure to body fluids.
Examples: Office-based worker with no patient contact and minimal public interactions
Isolation Mask Recommended
Any team member interacting with patients who are negative for COVID-19 or any
team member with significant public interaction are encouraged to wear isolation
mask and gloves (only if possible exposure to body fluid).
Isolation Mask Highly Recommended
Any team member participating in the care of patients who are positive for COVID-19 or with patients with respiratory symptoms where diagnosis not established, must wear isolation mask, eye protection, gown and gloves.
N95 Respirator Highly Recommended
Any team member participating in the care of patients who are positive for COVID-19 or patients under
investigation (PUI) for COVID-19 that are having aerosol-generating procedures or other procedures of
concern should wear an N95 respirator/PAPR/CAPR,
eye protection, gown and gloves.
Examples: nebulizer therapy, high flow oxygen therapy, BiPAP or CPAP, suctioning, bronchoscopy, intubation, CPR
N95 respirators may also be used at the point of
patient’s first contact with the health system when
judged appropriate by care providers, including initial
evaluation of patients.
*Adapted from guidance provided by BJC HealthCare
and Washington University Physicians. Images
adapted from How to Make Cloth Face Coverings,
Sequence for Putting on Personal Protective
Equipment (PPE), and COVID-19 Personal Protective
Equipment (PPE) for Healthcare Personnel from the
Centers for Disease Control and Prevention.
SHOW-ME SCHOOL-BASED HEALTH ALLIANCE OF MISSOURI 25
Appendix D—RECOMMENDATIONS FOR THE CONSERVATION OF PPE DURING COVID-19
OUTBREAK FROM ESSE HEALTH
SHOW-ME SCHOOL-BASED HEALTH ALLIANCE OF MISSOURI 26
Recommendations for the conservation of PPE during COVID-19 outbreak
Gowns
• Use a risk-based approach to prioritize the use of isolation gowns
• Consider alternatives – non-sterile surgical gowns and/or aprons
o during patient care were splashes and sprays are anticipated, including aerosol-generating activities
(e.g., nebulizer use)
Surgical facemasks
• Extend use where applicable
o Staff continues wearing the same isolation masks between close contact encounters with several
different patients, without removing the isolation mask between patient encounters.
o Minimize unnecessary contact with the surface of the isolation mask, strict adherence to hand hygiene
practices, and proper PPE donning and doffing technique.
o Do not pull the isolation mask down around his neck or place on top of the head between patient
encounters.
o Perform hand hygiene with soap and water or an alcohol-based hand sanitizer before and after touching
or adjusting the isolation mask.
• Discard isolation mask if
o Visibly soiled
o Moist or wet
• Process for reusing
o write first and last name and date of first use on a paper bag
o after use, remove surgical mask per standard doffing sequence
▪ If the facemask is NOT visibly soiled, torn or saturated, place on a paper towel, exterior side
down.
▪ Fold the paper towel with mask and place it in the pre-labeled bag for reuse.
o Discard the mask if visibly soiled, moist, or wet.
o To reuse, inspect the mask for damage. If not damaged, follow the below steps:
▪ Perform hand hygiene
▪ Retrieve mask from the bag and put on
▪ Perform hand hygiene
▪ Finish donning PPE as applicable
▪ Perform hand hygiene anytime mask is touched
N95 respirator
• N95 respirators may be used by providers (Physicians and Advanced Practice Providers) that are in close contact
with patients for greater than 5 minutes at a time.
• Respirators are to be used by the personnel involved with aerosol-generating procedures (e.g., nebulizer
treatments).
• Extend use where applicable
SHOW-ME SCHOOL-BASED HEALTH ALLIANCE OF MISSOURI 27
o Staff continues wearing the same N95 between close contact encounters with several different patients,
without removing the N95 between patient encounters.
o Minimize unnecessary contact with the surface of the N95, strict adherence to hand hygiene practices,
and proper PPE donning and doffing technique.
o Perform hand hygiene with soap and water or an alcohol-based hand sanitizer before and after touching
or adjusting the isolation mask.
• Reuse where applicable. A single wearer must only reuse N95 respirators.
• Discard N95 respirators if
o Visibly soiled
o Moist or wet
o Following use during aerosol generating procedures
• Process for reusing
o write first and last name and date of first use on a paper bag
o after use, remove surgical mask per standard doffing sequence
▪ If the facemask is NOT visibly soiled, torn or saturated, place it in the pre-labeled bag for reuse.
o Discard the mask if visibly soiled, moist, or wet.
o To reuse, inspect the mask for damage. If not damaged, follow the below steps:
▪ Perform hand hygiene
▪ Retrieve N95 from the bag and put on. Ensure a proper fit.
▪ Perform hand hygiene
▪ Finish donning PPE as applicable
▪ Perform hand hygiene anytime N95 is touched
• Discard any N95 that is damaged or becomes hard to breathe through.
• Pack or store N95 masks between uses so that they do not become damaged or deformed.
Goggles/Eye Protection
• Touch goggles with clean hands only.
• Disinfect goggles after each patient encounter with alcohol or other disinfectant wipes.
• Store in a way to prevent contamination until next use.
References
BJC – Recommended Conservation Strategies as of April 8th, 2020.
Ask the expert: N95 respirator reuse. OSHA Healthcare Advisor. http://blogs.hcpro.com/osha/2009/05/ask-the-expert-n95-respirator-reuse/
CDC - Recommended Guidance for Extended Use and Limited Reuse of N95 Filtering Facepiece Respirators in Healthcare Settings.
https://www.cdc.gov/niosh/topics/hcwcontrols/recommendedguidanceextuse.html
Updated 4/19/2020
SHOW-ME SCHOOL-BASED HEALTH ALLIANCE OF MISSOURI 28
Appendix E—MOSBHA CALLS FOR HEIGHTENED AWARENESS & PRIORITIZATION OF
STUDENT MENTAL HEALTH
SHOW-ME SCHOOL-BASED HEALTH ALLIANCE OF MISSOURI 29
MOSBHA Calls for Heightened Awareness & Prioritization of Student Mental Health
Mental Health Needs of Missouri Children and Youth
Prior to COVID-19, youth mental health was already a major concern for Missouri educators & caregivers, with
24% of Missouri children reported to have one or more emotional, behavioral, or developmental condition
during the 2017-2018 school year according to Kids Count. Many students receive mental & behavioral health
services through school-based mental health programs; nationally, according to research presented by the
National School-Based Health Alliance, 70% of children who receive mental health services access those
services at school.
With school closures beginning in mid-March 2020 and extending through the end of the 2019-2020 school
year, access to services previously received during school hours has essentially ceased. Given the unique
combination of the public health crisis, social isolation, and economic recession, as expanded upon in a recent
JAMA Pediatrics article, the COVID-19 pandemic will likely worsen existing mental health problems and lead to
more cases among children and adolescents.
Further, students, as well as teachers and staff, who may have suffered the loss of family members and loved
ones as well as significant changes to life circumstances due to COVID-19, will return to school dealing with
grief. The stress associated with this virus may understandably increase worry and anxiety in our students,
staff, families, and communities.
Role of School-Based Health Programs
School-based mental health programs (SBMHP) are in a
critical role to respond to the mental health needs of
children and adolescents exacerbated by COVID-19.
SBMHPs, typically sponsored by community mental health
centers (CHMCs) or federally qualified health centers
(FQHCs), provide a continuum of support for students,
including prevention and promotion curriculum, family and
group psychoeducation and therapy programs, and
individualized counseling & therapy.
Other types of school-based health (SBH) programs, such as
school-based health centers and telehealth programs, are
also in a position to address mental health needs
exacerbated by COVID-19. These programs often have staff
with trauma training and address holistic student needs
through referrals and wraparound services, both of which
may be further leveraged to support students.
What You Can Do—Guidance for School and School-Based Health Program Partners
The Alliance’s vision is that every child and youth in Missouri has an equal opportunity to succeed by
assuring access to high quality health and mental health care. Educators and healthcare providers—now more
than ever—can leverage their cross-sector partnerships to address the heightened need of our students. To
SHOW-ME SCHOOL-BASED HEALTH ALLIANCE OF MISSOURI 30
that end, we have provided the below guidance and resources for you to use and share with others in your
networks.
Prioritize addressing mental health needs by convening all stakeholders early and often in
preparation for the 2020/2021 school year.
o Critical stakeholders may include SBH program partners, school nurses, school counselors or
social workers, school leadership, teachers, parents, and students. It is important to include as
many voices as possible to understand the mental health needs, as well as existing resources
and supports, unique to each school and community.
o If you have not previously worked with a community mental health center, they may be able to
support by providing training, expertise, or resources as well as accept referrals. The MO
Department of Health has a map of community mental health centers – access here to find a
provider in your area.
Define common goals between all partners and streamline efforts to reduce duplication of efforts.
o Include messaging to address mental health needs in school’s reentry communication plan to
ensure consistent messages. The Missouri School Boards’ Association’s Pandemic Recovery
Guidance includes extensive guidance on developing an effective communications procedure.
o The National Association of School Psychologists and the American School Counselor
Association developed a guide on school reentry considerations and supporting student social
and emotional learning (SEL) amidst COVID-19 which may be helpful in determining priorities.
CASEL also developed a guide to leverage SEL in preparation for school reopening.
Leverage the resources and expertise of all partners to create a holistic and multi-tiered response to
mental health needs.
o Consider providing youth mental health first aid (YMHFA) to school staff and educators to
understand common mental health challenges for youth and how to assist them. The Center for
Education Safety at the MSBA provides YMHFA to all Missouri schools at no cost.
o SBH programs who did not previously provide mental health services in the school setting
should explore leveraging their sponsoring organization’s mental health resources to refer
students to increase access to mental health care.
o SBH programs have a critical opportunity to support the schools they serve in their crisis
management efforts, such as ensuring that all communications and services provided to
students and parents are developed and disseminated with a trauma-informed lens.
o Plan for conducting ongoing behavior/mental health monitoring and assessment for the school
community. See example screening form and questions here.
o SBH programs and school staff can work together to develop and provide educational materials
on loss and coping with stress for families, staff, and parents. The National Association of
School Psychologists provides tips for teachers and administrators on addressing grief.
o SBH providers can support school faculty and staff in identifying families in need of long-term
physical and mental health support and intervention.
SHOW-ME SCHOOL-BASED HEALTH ALLIANCE OF MISSOURI 31
Address the health and well-being of teachers and staff, in addition to students, to support an
environment of mental wellbeing.
o Schools and/or SBH programs can work together to provide counseling support services
available to faculty and staff via Employee Assistance Programs that are available.
o The SBH program can support schools to provide information to staff on signs and symptoms of
mental health issues or crisis to observe in themselves and in students.